Health care coverage: dementia

The law bars most step-therapy requirements for these treatments and limits coverage rules to FDA-approved uses, potentially reducing barriers to care.

What the law does ​

• Requires plans and policies issued, amended, or renewed on or after January 1, 2027, to cover medically necessary FDA-approved treatments and medications for Alzheimer’s disease and other conditions affecting memory.
• Applies coverage to treatments delivered under medical benefits and, where included, outpatient prescription-drug benefits.
• Prohibits step therapy for self-administered and physician-administered treatments, but allows it for other treatment types if at least one antiamyloid therapy is available without step therapy.
• Allows prior authorization and other utilization management if medical-necessity decisions follow the same standards used for other covered conditions.
• Bars coverage criteria more restrictive than the FDA-approved indication and treats authorization requests as exigent circumstances.
• Exempts specified dental-only, vision-only, limited-benefit, Medicare supplement, and Medi-Cal managed care coverage.

Who it affects ​

• People covered by qualifying California health plans or health insurance policies who have Alzheimer’s disease or another memory-affecting condition.
• Health care service plans and health insurers offering covered contracts or policies.
• Health care providers determining whether a treatment or medication is medically necessary.

Context ​

The requirements begin January 1, 2027, and do not apply to Medi-Cal managed care plans.